Current concepts
Diagnosis and treatment of chronic painful shoulder: Review of nonsurgical interventions

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Abstract

Chronic painful shoulder is a common complaint, yet its initial pathogenesis may have multiple etiologies as well as multiple and perhaps distinct primary or secondary etiologies responsible for its final clinical presentation. While the clinical presentation of pain and limitation of motion is easily defined, there are no standardized criteria for the differential diagnosis of various chronic shoulder pain syndromes, much less a consensus on their treatment. At present, there are limited nonsurgical options and medications approved for the treatment of chronic painful shoulder, and, with limited exceptions, there are no definitive conclusions about the efficacy of these therapies based on controlled clinical studies reported in the literature. There is a clear clinical need for local nonsurgical treatments that are safe and effective for chronic painful conditions. In this article, an attempt is made to review the diagnoses associated with chronic shoulder pain and some of the limited data that exist so as to suggest a therapeutic algorithm.

Section snippets

Etiology of shoulder pain

The anatomy of the shoulder is complex and is composed of bone, muscles, tendons, and ligaments. The shoulder joint itself is made up of 4 articulations: the glenohumeral joint, sternoclavicular joint, acro-mioclavicular joint, and scapulothoracic articulation.6 Chronic dysfunction of any one component can result in failure of other components and potentially irreversible structural damage. The precise cause(s) of shoulder pain within the joint structure is unknown. However, it is presumed to

Acute versus chronic pain

Acute pain is defined as pain associated with actual or potential tissue damage, which is of recent onset and probably limited duration.16 Acute pain usually has an identifiable relationship to injury or disease, whereas chronic pain commonly persists beyond the time of healing and often has no identifiable cause.16 Importantly, there is no absolute distinction between acute and chronic pain, but the temporal transition is most often reflected in the ineffectiveness of the initial intervention.

Diagnosis of shoulder pain

The differential diagnosis of shoulder pain remains a challenge for physicians and there is much discrepancy in the literature regarding diagnostic criteria. Indeed, in a study in which 3 consultants separately examined the same 26 patients with shoulder pain, complete diagnostic agreement was reached in only 46% of cases.24 In another study of 201 patients with shoulder pain who were independently examined by 2 physiotherapists, the percentage of diagnostic agreement was 60%.25 Similar studies

Differential diagnosis of chronic regional pain syndrome

Although not the prime focus of this review, which covers chronic shoulder pain of musculoskeletal origin, there are aspects of chronic shoulder pain that do not have a musculoskeletal etiology but are neurologic-based disorders, such as chronic regional pain syndrome or reflex sympathetic dystrophy (RSD). Differentiating these patients from those with pain disorders with a musculoskeletal pathophysiology is important, particularly in those with severe or burning pain. These patients may have

Osteoarthritis

Early symptoms of OA are characterized by pain with use.32 However, as the disease advances, there may be pain at rest and limitation of joint function. Moderate pain on shoulder movement with crepitation and functional limitation may be seen on physical examination and direct palpation over the joint may elicit pain and tenderness. Abduction against a fixed scapula isolates the movement of the glenohumeral joint and aids diagnosis.

Rotator cuff tear

Rotator cuff tears are characterized by pain at the lateral,

Radiograms and arthrograms

Plain radiography is the first step in diagnostic imaging, and may be used to diagnose OA, tendinitis or bursitis (Table 2).11 Arthrography was the diagnostic test of choice before MRI.11 While arthrography is able to identify complete rotator cuff tears, bursitis, or adhesive capsulitis, it is invasive and relatively poor at diagnosing a partial rotator cuff tear.11, 17

Computed tomography, MRI, and ultrasound

Computed tomography (CT) scanning may be useful in diagnosing bony lesions, subtle dislocation, labral tears, and full rotator

Acute painful shoulder

Current therapy for acute painful shoulder includes rest and physical therapy,3, 40 oral nonsteroidal anti-inflammatory drugs (NSAIDs),3, 40, 41, 42 intra-articular corticosteroids,3, 40, 42 or intra-articular sodium hyal-uronates.43, 44 Of note, a 2002 Cochrane report concludes that there is insufficient evidence to support or refute the benefit of corticosteroids in treating shoulder pain.45

Chronic painful shoulder

Current nonoperative treatment for chronic shoulder pain is initially conservative, using rest, ice,

Conclusions

Conditions of the shoulder are a common cause of chronic musculoskeletal pain and contribute to the considerable lost productivity and high cost associated with this form of chronic pain. Currently, a paucity of information exists regarding the relative significance of individual underlying pathologies, or of the interrelation between them in eliciting the final clinical symptoms. It appears that the various symptoms associated with chronic shoulder pain are not exclusive and may represent a

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